Child And Adolescent Psychiatrists Research Articles

Integrated Behavioral Health Care in Pediatric Subspecialty Clinics.

Comorbid behavioral and physical health conditions are accompanied by troubling symptom burden, functional impairment, and treatment complexity. Pediatric subspecialty care clinics offer an opportunity for the implementation of integrated behavioral health (BH) care models that promote resiliency. This article reviews integrated BH care in oncology, palliative care, pain, neuropsychiatry, cystic fibrosis, and transplantation. Examples include integrated care mandates, standards of care, research, and quality improvement by child and adolescent psychiatrists (CAPs) and allied BH clinicians. The role of CAPs in integrated BH care in subspecialty care is explored, focusing on cost, resource use, financial support, and patient and provider satisfaction.

Unaccompanied Latino Minors, Immigration, and Mental Health: An Opportunity for Advocacy

Child and adolescent psychiatrists (CAPs) have a duty to be patient advocates in multiple ways. Indeed, the Child and Adolescent Psychiatry Milestone Project’s inclusion of advocacy within the systems-based practice competency recognizes this role as a core element of practice. However, while training programs focus on teaching advocacy for individual patients’ needs, such as securing insurance coverage for medical treatment or obtaining school accommodations, preparedness in public policy and social justice domains is often limited. Accordingly, the current president of the American Academy of Child and Adolescent Psychiatry (AACAP), Dr. Gregory Fritz, has highlighted advocacy as one of four areas that his presidential initiative on integrated care will tackle.1 The main goals of this article are to discuss the role of CAPs in advocacy efforts as they apply to the vulnerable population of unaccompanied children from Central America, to discuss ways in which CAP training programs can promote the special interests and advocacy efforts of their trainees, and to encourage all CAPs to consider ways to amplify their voices and roles as children’s advocates.

Neurodevelopment disorders in adolescence and transition into adulthood

The transitional period from adolescence into adulthood is an important developmental stage, known to be a risk factor for mental health problems. Neuropsychiatric disorders are the main cause of disability for young people aged 10–24 years and they seem to precede mental health disorders in adults. Since persistence of an adolescent episode is a strong predictor of outcome, giving proper care during critical stages might prevent later life psychiatric morbidity arising from adolescent-onset disorders. Mental health services for adolescents have evolved from non-specific secondary treatment to more extensive treatment goals, where prevention and early diagnosis take place; at the same time, specific therapeutic tools for adolescents are increasing and put into practice. In Europe, both child and adolescent psychiatrists (CAP) and adult psychiatrists treat adolescents, and for a few countries, the specialty of adolescent psychiatry exists. In this symposium, we propose to address new strategies to treat adolescents with defying pathologies that often pose problems; we will do it through the scope of CAP and adult psychiatry.Disclosure of interestThe author has not supplied his declaration of competing interest.

Criminality among Former Child and Adolescent Psychiatric Patients and Matched Controls

Background: Externalizing symptoms in children (aggression, oppositionality, property and status violations), and the Attention Deficit Hyperactivity Disorder (ADHD) triad of problems (inattention, hyperactivity, impulsivity) display a substantial co-morbidity. The “short temper” problem is common to these syndromes, which are predictive of a range of negative life outcomes including substance abuse and criminality in adulthood. There is a gender gap for the syndromes (boys are more affected), for criminality (men are more criminal) and knowledge (we know less about girls’ criminal careers). Aims: The main aim was to compare crime rates and crime profiles among former Child and Adolescent Psychiatric (CAP) patients with corresponding data for matched controls, focusing externalizing and internalizing psychiatric symptoms, sex and adverse social factors. Method: Data for 6055 former CAP-Stockholm outpatients were extracted from available treatment registers. For each CAP patient, two matched controls from the general population were randomly selected from the same area of residence, of the same sex and with the same year of birth (N approx. 12,000). Data on criminality for these individuals were obtained from a Swedish police register which also includes crimes committed prior to age 15. Results: Overall, twice as many former CAP patients were registered for crimes at a mean age of 21.4 compared to the controls. The over-representation was larger for crimes of violence. Females were registered for a much lower number of crimes, particularly crimes of violence (gender gap). The gender gap among the CAP patients was smaller than among controls. Compared with controls, CAP patients characterized by externalizing problems at referral had an odds ratio (OR) for crimes of 5 for males and 10 for females. Neglect was the only adverse social factor which was associated with a higher crime rate and affected boys more than girls. Compared to previous Swedish CAP cohorts, the criminality of the current cohort was much higher. Conclusion: In-depth studies of female crime careers characterized by externalising problems are needed. Child psychiatric services must find new and more effective ways of identifying and treating children with such problems, regardless of sex. The findings can guide the choice of strategies which will reduce crime rate.

Teaching a Systematic Approach for Transitioning Patients to College: An Interactive Continuing Medical Education Program.

The purpose of this article is to determine the effectiveness of a hands-on continuing education program for practicing child and adolescent psychiatrists (CAPs) with a focus on best practices in transitioning psychiatric patients to college. The plan was to build on the unique knowledge and skill set of CAPs, use audience and facilitator feedback from prior programs to inform program content, structure, and format, and incorporate findings from the evolving literature. A 3-h interactive workshop was designed with an emphasis on audience participation. The workshop was divided into three main segments: didactics, whole group discussion/brainstorming, and small group discussion of illustrative case vignettes. Improvements and changes in knowledge, skills, and attitudes related to transition planning were identified by program participants. Quantitative feedback in the form of course evaluations, pre- and posttests, and a 6-month follow-up questionnaire indicate that the use of interactive teaching techniques is a productive learning experience for practicing CAPs. Qualitative feedback was that the discussion of the case vignettes was the most helpful. The use of a workshop format is an effective strategy to engage practicing CAPs in learning about and implementing best practices to support the transition of their patients to college and into young adulthood. Comprehensive and proactive transition planning, facilitated by clinicians, should promote the wellness of college-bound patients and help to reduce the potential risks in the setting of an upcoming transition.

A Model CSMH Curriculum for Child and Adolescent Psychiatry Training Programs.

Child and adolescent psychiatrists (CAP) care for high school students preparing to enter college. They also may continue to see students while on school vacations and may care for college students in various settings (emergency room, inpatient hospital unit, private practice, college student health service, or counseling center). As increasing numbers of students with mental health diagnoses pursue secondary education, CAP need to be knowledgeable about campus systems of care, principles of transition, and privacy and educational laws affecting college students. This article describes an informal needs assessment of general CAP members of the American Academy of Child and Adolescent Psychiatry and details the results of a survey of CAP program directors on training opportunities in college student mental health (CSMH). The authors present a sample curriculum for a clinical rotation in CSMH, as well as providing ideas for core didactic lectures, and proposing the development of online resources to reduce the burden of creating new lectures and standardize experiences among training programs.

Innovations in Practice: 'Off-label' clonidine: UK Paediatric and Child and Adolescent Psychiatry prescribing practice for sleep problems.

Psychopharmacological prescribing of clonidine has been described in Australia and in the United States but not in Europe. This study explores UK clinician experience of clonidine 'off label' in treating paediatric sleep problems in the context of a paucity of evidence for its use. Survey of UK Child and Adolescent Psychiatrists (CAPs) and specialist Paediatricians. Of 389 respondents (30% Paediatricians, 70% CAPs), 172 prescribed clonidine and 85 having used it for treating sleep. Treatment targets were sleep onset, night waking and nonspecific sleep problems, and carer respite, in patients with significant coexisting neurological and neurodevelopmental disorders. Most used clonidine as a second line medication after trying nonpharmacological approaches. The majority reported initial effectiveness, and adverse effects were mild or transient. Issues of reducing long-term effectiveness, drug tolerance and considerable differences in dosing regimes were identified. Clonidine use appears less widespread in the United Kingdom than reported elsewhere. It is seen as a potentially effective and safe intervention but this study highlights the need for good quality RCT evidence for the most effective use of clonidine in paediatric sleep disorders.

Multi-professional team as a post NPM control regime


 
 
 This paper focuses on multi-professional teams (MPT) as a potential post New Public Management (NPM) control regime in order to develop individualistic and holistic care in healthcare in the context of two competing logics: managerialism and professionalism. In a qualitative case study, three outpatient Child and Adolescent Psychiatric (CAP) care units are investigated using interviews, observations and shadowing. The study shows that the MPT has an integrative effect on the two logics when informal alliances are formed between psychologists/psychiatrists and unit managers. We conclude that the MPT may achieve patient care in a resource-effective and professional way but not individualistic and holistic care. An explanation may be that individualistic and holistic care is neither measurable/quantifiable as required by the resource-effectiveness goal nor in focus as a consequence of the logic of professionalism. A theoretical implication is that the negative effect of NPM on the professionals’ autonomy is mitigated by the MPT. Earlier studies may have underestimated the importance of “hard facts” introduced by a strong control regime, in this case, the NPM context. The control regime may take over and create collaboration; nonetheless, the outcome is not entirely the desired one.
 
 

The use of Clonidine outside its licensed indication in paediatric psychopharmacology: a UK survey of current practice

<h3>Aims</h3> To ascertain current practice, experience and opinion among UK clinicians of the use of Clonidine for the treatment of conditions such as tics and behavioural disturbances, with particular focus on sleep problems. <h3>Methods</h3> Electronic survey sent to all Child and Adolescent Psychiatrists (CAPs) and Paediatricians in selected specialties. 389 respondents (116 Paediatricians, 273 CAPs). <h3>Results</h3> 172 (44%) respondents prescribed Clonidine in the last year, most commonly for (in decreasing order of frequency) tic disorders, sleep problems, hyperactivity and aggression. CAPs were more likely to prescribe for hyperactivity; Paediatricians for sleep problems. Patient numbers ranged from 0-100 with Paediatricians having the largest caseloads. Over 90% practised in line with NICE attention deficit hyperactivity disorder (ADHD) guidelines regarding initial physical/cardiovascular examination, but not in the use of electrocardiograms. After initiation, 78% monitored blood pressure. The majority reported a good level of short-term effectiveness in tics, sleep and hyperactivity, but some reduction in effect in long-term use, especially for sleep. 59% experienced drug tolerance which had an impact on ultimate efficacy. Adverse effects, reported by 54%, were generally considered mild. 53 respondents (31%) prescribed for a range of sleep problems including movement disorders, for children aged 2-18 years, predominately with neurodevelopmental disorders. 94% reported using drugs as second line treatment. Initiation dose, titration regime and maximum doses showed considerable variation but within the broad parameters described in the literature. In general, there were no significant differences in practice evident between Paediatricians and CAPs. 272 respondents had not prescribed Clonidine, not managing relevant conditions, not knowing how to use it or because of concerns about safety or effectiveness. Despite this, 92% of all respondents said they would find clinical guidelines helpful for their practice. <h3>Conclusion</h3> There is a lack of rigorous evidence for tics and behaviour and only anecdotal evidence for sleep. This survey suggests: The use of Clonidine by both professions is mostly appropriate, albeit on the basis of limited evidence. A lack of knowledge about a potentially useful drug for which clinical guidelines would be helpful. A need for properly constructed, large scale, randomised controlled trials for Clonidine, particularly in sleep disorders.

Innovations in Practice: Child and adolescent psychiatrists and primary care - innovative models of consultation in the United States.

There is a severe shortage of child and adolescent psychiatrists (CAPs) in the United States, an increasingly recognized high prevalence of mental disorders in young people, and widely supported goals to provide more mental health services in the primary care setting. A number of innovative, state-wide or more local, publically funded programs have been developed in the United States over the last several years to respond to these challenges and to provide CAP consultation to primary care physicians (PCPs) who wish to address the mental health disorders of their patients in the primary care setting. A number of these programs and their approaches to consultation are described. An example of a clinical scenario that might be addressed using this model of CAP/PCP collaboration is offered. An innovative model of consultation to PCPs from CAPs appears able to facilitate the treatment of many young people with mental health disorders in the primary care setting.

Pathways to child and adolescent psychiatric clinics: a multilevel study of the significance of ethnicity and neighbourhood social characteristics on source of referral.

BackgroundIn the Swedish society, as in many other societies, many children and adolescents with mental health problems do not receive the help they need. As the Swedish society becomes increasingly multicultural, and as ethnic and economic residential segregation become more pronounced, this study utilises ethnicity and neighbourhood context to examine referral pathways to child and adolescent psychiatric (CAP) clinics.MethodsThe analysis examines four different sources of referrals: family referrals, social/legal agency referrals, school referrals and health/mental health referrals. The referrals of 2054 children aged 11-19 from the Stockholm Child-Psychiatric Database were studied using multilevel logistic regression analyses.ResultsResults indicate that ethnicity played an important role in how children and adolescents were referred to CAP-clinics. Family referrals were more common among children and adolescents with a Swedish background than among those with an immigrant background. Referrals by social/legal agencies were more common among children and adolescents with African and Asian backgrounds. Children with Asian or South American backgrounds were more likely to have been referred by schools or by the health/mental health care sector. A significant neighbourhood effect was found in relation to family referrals. Children and adolescents from neighbourhoods with low levels of socioeconomic deprivation were more likely to be referred to CAP-clinics by their families in comparison to children from other neighbourhoods. Such differences were not found in relation in relation to the other sources of referral.ConclusionsThis article reports findings that can be an important first step toward increasing knowledge on reasons behind differential referral rates and uptake of psychiatric care in an ethnically diverse Swedish sample. These findings have implications for the design and evaluation of community mental health outreach programs and should be considered when developing measures and strategies intended to reach and help children with mental health problems. This might involve providing information about the availability and accessibility of health care for children and adolescents with mental health problems to families in certain neighbourhoods and with different ethnic backgrounds.

The effectiveness of child and adolescent psychiatric treatments in a naturalistic outpatient setting

Data concerning the effectiveness of naturalistic treatments (treatment-as-usual) in child and adolescent psychiatric (CAP) services are scarce. The purpose of this prospective observational study was to examine the effectiveness of CAP treatments in a naturalistic outpatient setting. Three hundred six patients (attention-deficit/hyperactivity disorder, ADHD, n=94; conduct disorder, CD, n=57; anxiety disorder, AD, n=53; depressive disorder, DD, n=38; other diagnostic categories, n=64), from nine child and adolescent psychiatric practices in Germany, were evaluated. Treatment effects were compared between patients who received frequent treatment and patients who only participated in diagnostics and short interventions. Since randomization was not feasible, propensity score analysis methods were used. Regarding the total sample, no significant treatment effects were found. However, a subgroup analysis of the four most frequent disorders (ADHD, CD, AD, DD) showed small to moderate treatment effects in patients with ADHD and AD. In CD and DD subgroups, no significant treatment effects could be found. "Real-world" CAP outpatient treatment seems to produce significant effects for ADHD and AD, but not for CD and DD. Compared to efficacy studies, our results show that naturalistic treatment might be better than expected.

Symptoms Leading to a Bipolar Diagnosis: A Phone Survey of Child and Adolescent Psychiatrists

We surveyed child and adolescent psychiatrists (CAPs) to characterize how they diagnose bipolar disorder (BPD) in children. We approached by mail and then telephone 100 CAPs randomly sampled from five regions of the main professional organization of American CAPs; 53 CAPs were reached and agreed to participate. We asked about their training and practice setting, and asked them to name 10 symptoms indicative of BPD. We conducted descriptive analyses to determine how CAPs ranked symptoms, whether reports were consistent with Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) criteria, and whether alternative symptom models might guide their decision making. CAPs considered lability, grandiosity, family history of BPD, aggression, and expansive or euphoric mood as the most important factors in diagnosing BPD. Only 21 (39.6%) CAPs reported sufficient symptoms to meet DSM criteria for BPD (DSM-Yes status). DSM-Yes status was associated with participants' region, less expertise (< or =10 years practicing child and adolescent psychiatry), and lower levels of self-reported confidence in their ability to diagnose BPD. CAPs vary in the symptoms they use to diagnose BPD, with most using a mixture of DSM and non-DSM symptoms. Expertise and confidence may lessen one's reliance on DSM criteria. Further studies are needed to understand CAPs' diagnostic decisions about BD and to develop interventions to support accurate diagnostic decision making and improve patient care.

The Role of Nurse Practitioners in Meeting the Need for Child and Adolescent Psychiatric Services: A Statewide Survey

The high prevalence of child and adolescent mental health disorders coupled with shortages in age-appropriate mental health services pose a significant problem likely to be exacerbated over time. A survey was designed to identify the current status of and need for child and adolescent psychiatrists (CAPs) and mental health services, as well as strategies and recommendations to address identified needs in the state of New York. Key informants from each county and New York City were surveyed by telephone (N = 58). Most respondents identified a shortage of child and adolescent psychiatry services and reported that when CAPs are unavailable, nurse practitioners (NPs) are currently among the top four professional groups who prescribe and/or monitor psychotropic medication. Almost half of the respondents (48%) identified employing NPs with advanced certification in child and adolescent psychiatry as a promising strategy to improve access to care. Addressing the shortage of CAPs can provide an opportunity for the nursing profession to advance its role in the provision of mental health services to youth.

Pediatricians' Role in Providing Mental Health Care for Children and Adolescents: Do Pediatricians and Child and Adolescent Psychiatrists Agree?

Many children who have a mental health disorder do not receive mental health services and are seen only in primary care settings. Perceptions of pediatricians and mental health specialists regarding the role that pediatricians should have in diagnosing and managing children's mental health problems have not been studied. To examine whether primary care pediatricians (PCPs) and child and adolescent psychiatrists (CAPs) agree about: (1) the pediatrician's role in identification, referral, and treatment of childhood mental health (MH) disorders; and (2) barriers to the identification, referral, and treatment of childhood MH disorders. Surveys were mailed in 2005 to 338 PCPs and 75 CAPs in 7 counties surrounding Cleveland, Ohio. Each group was asked whether they agreed that PCPs should be responsible for identifying, treating, or referring 7 prevalent childhood MH problems. Barriers that PCPs face in identification, referral, and treatment of MH problems were also assessed. Analyses were weighted for nonresponse; group differences were assessed via Rao-Scott chi test and weighted regression analyses. Approximately half of PCPs and CAPs returned the survey. With the exception of attention deficit hyperactivity disorder (ADHD), the majority of PCPs and CAPs agreed that pediatricians should be responsible for identifying and referring, but not treating child MH conditions. For ADHD, PCPs were more likely than CAPs to agree that pediatricians should identify and treat affected children. PCPs were more likely than CAPs to agree that pediatricians should be responsible for identifying child/adolescent depression and anxiety disorders; the majority of both groups agree that PCPs should be responsible for referring, but not treating these conditions. Both groups agree that lack of MH services is a barrier to identification, treatment, and referral of child MH problems for PCPs. CAPs were more likely to agree that pediatrician's lack of training in identifying child mental health problems was a barrier, whereas PCPs were more likely to endorse lack of confidence in their ability to treat child MH problems with counseling, long waiting periods to see MH providers, family failure to follow through on referrals, and billing/reimbursement issues as barriers. Most PCPs and CAPs believe it is pediatricians' responsibility to identify and refer, but not treat, the majority of children's mental health problems. Both groups agree that mental health services are not readily available. Future efforts are needed to support PCPs and CAPs in their combined effort to address the mental health needs of children.

Child and adolescent psychiatric patients and later criminality

BackgroundSweden has an extensive child and adolescent psychiatric (CAP) research tradition in which longitudinal methods are used to study juvenile delinquency. Up to the 1980s, results from descriptions and follow-ups of cohorts of CAP patients showed that children's behavioural disturbances or disorders and school problems, together with dysfunctional family situations, were the main reasons for families, children, and youth to seek help from CAP units. Such factors were also related to registered criminality and registered alcohol and drug abuse in former CAP patients as adults. This study investigated the risk for patients treated 1975–1990 to be registered as criminals until the end of 2003.MethodsA regional sample of 1,400 former CAP patients, whose treatment occurred between 1975 and 1990, was followed to 2003, using database-record links to the Register of Persons Convicted of Offences at the National Council for Crime Prevention (NCCP).ResultsEvery third CAP patient treated between 1975 and 1990 (every second man and every fifth woman) had entered the Register of Persons Convicted of Offences during the observation period, which is a significantly higher rate than the general population.ConclusionResults were compared to published results for CAP patients who were treated between 1953 and 1955 and followed over 20 years. Compared to the group of CAP patients from the 1950s, the results indicate that the risk for boys to enter the register for criminality has doubled and for girls, the risk seems to have increased sevenfold. The reasons for this change are discussed. Although hypothetical and perhaps speculative this higher risk of later criminality may be the result of lack of social control due to (1) rising consumption of alcohol, (2) changes in organisation of child social welfare work, (3) the school system, and (4) CAP methods that were implemented since 1970.

Is bipolar II disorder misdiagnosed as major depressive disorder in children?

Objectives: To estimate the lifetime prevalence of bipolar II disorder in children and adolescents presenting with DSM-IV major depressive disorder (MDD). Methods: Sixty-one consecutive subjects aged ≤ 18 years attending the outpatient services of the Child and Adolescent Psychiatric (CAP) services of the National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India with a diagnosis of MDD were evaluated using the Missouri Assessment of Genetics Interview for children (MAGIC). Two psychiatrists, one of whom was a child psychiatrist diagnosed hypomania by consensus. Results: Twelve children had a past episode of hypomania (20%), which was hitherto undiagnosed clinically. Limitations: We recruited subjects from a psychiatric hospital, thus limiting the generalizability of the finding. Sample size was relatively small and assessments were cross-sectional. Conclusions: Our study shows that bipolar II disorder is often misdiagnosed as MDD in children. The study also highlights that the chance of diagnosing bipolarity is enhanced by using semi-structured interview in routine clinical practice.

Medical Students' Perceptions of Child Psychiatry: Pre- and Post-Psychiatry Clerkship

The U.S. is facing a severe shortage of child and adolescent psychiatrists (CAPs). While medical students have been relatively disinterested in psychiatry, little research has examined their perceptions of CAP. The present study examined student perceptions of CAP and general psychiatry, and whether these perceptions changed during the psychiatry clerkship. Students completed questionnaires assessing their perceptions of CAP and general psychiatry as a career choice on the first and last day of their clerkship. The opportunity to help children was most frequently perceived to be a positive aspect of CAP. The most frequently reported negative aspects were that CAP is emotionally stressful, a perception that decreased during the clerkship, and that there is a lack of family/societal support for children, a perception that increased during the clerkship. More students reported that CAP is respected compared to general psychiatry. Students estimated CAP salaries to be higher than general psychiatry salaries, but only at the end of the clerkship. Implications for the recruitment of medical students into CAP are discussed, including the potential importance of exposing students to diverse patient populations and requiring a CAP experience during the clerkship.

Long-term follow-up of adolescent onset anorexia nervosa in northern Sweden

Objective This study examines the long-term outcome of adolescent onset anorexia nervosa, 8 and 16 years after first admission to child and adolescent psychiatric (CAP) treatment in northern Sweden. Method Two follow-ups (1991 and 1999) were made of 68 women who were first admitted to CAP between 1980 and 1985. The follow-ups included interviews and self-report inventories. Eating disorders and GAF were evaluated according to DSM-III-R. Results Recovery increased from 46 (68%) to 58 (85%). EDNOS (eating disorder not otherwise specified) decreased from 16 (24%) to seven (10%). The numbers for anorexia nervosa (AN) were the same, two (3%) in both follow-ups. Bulimia nervosa (BN) decreased from four (6%) in the first follow-up to one (1.5%) in the second follow-up. The mortality rate was one (1%). Self-evaluation of mental health indicated that 15% had problems with depression, anxiety or compulsive symptoms. Somatic problems and paediatric inpatient care during the first treatment period could predict long-term outcome. Most former patients had a satisfactory family and work situation. Conclusion Recovery from eating disorders continued during the follow-ups. Copyright © 2005 John Wiley & Sons, Ltd and Eating Disorders Association.

Ethnic Diversity Among Child and Adolescent Psychiatric (CAP) Clinic Attenders

There is growing interest in the provision of health services that are sensitive to the needs of diverse ethnic groups. This paper examines ethnic diversity of attenders at a Child and Adolescent Psychiatric Clinic and how these groups differ in terms of referral route, reason for referral, psychiatric diagnosis and school report of difficulties. Service access relative to the distribution of the local population is assessed. Modification of OPCS categories provides additional useful information. The findings are relevant for the planning and provision of child and adolescent psychiatric services in a highly diverse population.